USMLE Step 1: Pass/Fail & What It Means for Med Students
- Sep 14, 2021
Dr. Brian Radvansky contributed to this post.
Though the USMLE Step 1 passing score is currently 194, after years of debate, the Invitational Conference on USMLE Scoring (InCUS) announced their long-awaited decision to transition the USMLE Step 1 to only a pass/fail outcome.
Here are the answers to the questions we’ve received so far regarding the Step 1 scoring change:
1. When will USMLE Step 1 become pass/fail?
Test administrations taking place on or after January 26, 2022 will transition to pass/fail score reporting.
2. Will Step 2 CK and Step 3 become pass/fail also?
USMLE Step 2 CK and Step 3 will still be reported based on numerical score outcomes.
3. Why is Step 1 changing to a pass/fail scoring system?
The USMLE Step 1 (and usually Step 2 CK) are taken during medical school, before applying to medical residencies. The score students receive on Step 1 has been treated with a great deal of emphasis and consideration by residency programs when screening and selecting applicants. As you would imagine, this causes a tremendous amount of stress for students preparing for Step 1 — and for the Match.
When the USMLEs were created in 1992, the creators did not envision a world in which the numerical scores would be given such weight when selecting residents, largely due to the inherent limitations of summing up an applicant’s skills and experiences with a number.
Additionally, medical schools have had to essentially balance educating and training future generations of doctors while increasingly teaching to these standardized exams over time.
In general, student engagement has decreased as they neared taking Step 1, often opting to give their full focus and attention to preparing for Step 1 rather than their medical coursework, often resulting in falling attendance at medical school lectures and widening philosophical disputes between students and Deans about efficient uses of their time.
Moving toward a pass/fail system, per the coalition, is hopefully a sign of system-wide changes to come, which will ideally bring more emphasis to demonstrating competencies in other ways, increasing diversity within different specialty programs, defining and selecting applicants not just based on numerical scores, but from a more well-rounded perspective.
4. What will Step 1 pass/fail score reporting look like?
According to the USMLE’s June 29, 2021 bulletin, Step 1 score reporting on the new pass/fail system will report passing scores as “pass” only.
For those who fail Step 1, the USMLE will offer content category-specific feedback regarding the examinee’s performance as it compares to other test takers. Examinees who fail Step 1 will also receive an illustration indicating the distance between his or her score and the minimum passing score.
5. Will I be affected by the change to pass/fail for Step 1?
If you’re currently in medical school and will be taking Step 1 prior to January 2022, you will still need to pass your Step 1 with a score of 194 or higher.
It’s impossible to know for sure how a pass/fail USMLE Step 1 will affect the residency admissions process. Since many schools have to sift through hundreds—if not thousands—of applications, many residency directors rely on certain key metrics to stratify applicants they should interview.
With the change in Step 1 scoring, added weight will certainly be given to a student’s Step 2 CK score and their clinical grades. This will substantially increase the importance of end-of-rotation shelf exams. We believe that letters of recommendation, research activities, and CVs in general will likely become increasingly important as well.
In our opinion, medical residency programs will likely start to place more emphasis on considering a medical school’s reputation when selecting residents for their program.
If you are not yet in medical school, we believe that this transition will likely make the MCAT an even more important factor in the long run, because it ties into where you will ultimately attend medical school. What will remain to be seen is what kind of impact this may have for residency applicants from lesser-known schools or DO applicants to ACGME programs.
6. How important will Step 2 CK become once Step 1 is pass/fail?
Only time will tell how important Step 2 will be in a Step 1 pass/fail world. Step 2 has the advantage of being a more clinical test than the basic science-based Step 1. After all, your knowledge of managing heart failure, pneumonia, and acute kidney injury are likely more important throughout your career than memorizing all of the CD-# cell-surface markers, every intermediary of glycolysis, and the finer points of inborn errors of metabolism.
7. How else will I stay competitive for residency when Step 1 is pass/fail?
Outside of your Step 2 score, and grades (which some medical schools have already eschewed for pass/fail systems), markers of character, dedication, reliability, humanism, empathy, and how hard you are willing to work will become the new yardsticks to determine who is cut out for limited residency slots.
A lot of these shine through in letters of recommendation. Have an attending transcribe into black and white, the times when you were so dedicated and empathic, and these qualities are vetted for.
What the Step 1 pass/fail decision means for the future of med school:
Once the change to Step 1 scoring goes into effect, no longer will medical students put all of their eggs into the USMLE basket, hoping to ride a solid Step 1 score into a specialty of their choosing. No longer will they spend countless hours at the library, trying to eke out the last couple of points to differentiate themselves from other high-performers.
The name of the game will be passing USMLE Step 1, and for ~90% of medical students, the playing field will be leveled.
So, instead of asking ourselves how to get the highest Step 1 score possible, which was central to just about everything before the change, we must revisit the initial question that brought us here:
As a medical student, what can I do to build the fulfilling, financially and emotionally rewarding career that I want?
We can take a more short-term view, and the question becomes:
As a medical student, what can I do to secure a residency spot in the program and specialty I want?
After all, it will be this residency that builds the bridge to and properly trains you to construct the aforementioned career.
The answer to this question used to be, “It all starts with a fantastic Step 1 score.”
Now, it starts with a passing Step 1 score.
But it starts so much earlier than that. As we move away from the metric-based reductionist approach to assessing residency candidates, the intangible, harder to qualify elements of character will become increasingly more important.
In the short term, a new metric will have to serve as the key to opening doors to residency interviews. And the natural place to look is Step 2 CK: another knowledge-based test that will deliver a three-digit score that the world of interviewers and program directors have become accustomed to. A single number that can give a pretty quick and accurate assessment of a candidate’s fund of knowledge, ability to perform under certain pressures, and likelihood of one day passing their specialty’s boards.
How to ensure you can put together a top-notch residency application in a Step 1 pass/fail world:
1. Be willing to work harder than the next student, keeping in mind that reputations develop early.
Put yourself in your future program director’s shoes. What do you care about in an applicant? You want your patients to do well–the central driver of anything in medicine. How do patients do well? When the resident taking care of them has a head on his or her shoulders and can get the work done safely and efficiently.
In the infancy of your medical career, efficiency is not a concern. It all comes down to learning as much as possible, and applying that knowledge to take care of patients. Taking care of patients, in an overly reductionist but relatively accurate approach, involves hundreds of small tasks that must get done. Multiply these tasks by multiple patients, and, if you haven’t discovered this already, the amount of work you will be expected to do, especially in residency, is more than you have likely ever done before.
And that’s all right. There’s nothing wrong, or bad, or untoward, about doing a lot of hard work. It’s a positive thing that will turn you into a relative machine. As your efficiency and pattern-recognition improve, everything will get that much easier, and you will have the capacity to take on even more.
The amount of effort that a medical student puts into the task(s) at hand is apparent both on the micro and macro level. Within a quick overview of an application and a few minutes of chatter, an interviewer will get a pretty good sense of your work ethic.
And at this stage, there are few things more important than having a strong work ethic that has been tested during medical school. The hardest worker who wasn’t challenged, or did not choose to challenge himself, will be no better off than the student who struggled to grasp the concept of patient care. That is, smarts don’t matter as much as the desire to learn and improve.
Find a way to pull all of the meaning, experience, and learning out of your medical school experience, and not only will you be tremendously better off for it, it will be obvious to everyone around you.
2. Get involved in a research project early.
The question on every student’s mind: Do I have to do research to match into specialty X? Maybe, maybe not. But will your application be stronger with multiple publications or without any? As long as your grades won’t suffer, it behooves you to get involved in some research project, even if you only have had a peripheral exposure to a specialty. It will not hurt you to have a paper published in an ophthalmology journal during your MS1 year when it comes time to apply to Internal Medicine.
You are going to be exposed to research throughout your career. It is what drives the decisions we make in medicine every day. The better handle you have on what it means to perform research, how to not only search through, but to objectively analyze the literature, the smarter physician you will become.
A publication is a tangible thing that makes an indelible mark on your CV. Being an author on a completed publication is far more impressive than “having done some research” in the summer between MS1 and MS2 year. Do what it takes to get published.
3. Explore specialties early on, but realize your limited level of consciousness.
The extra-curricular exploration of specialties will not only expose you to facets of medicine you wouldn’t have otherwise seen, but it will get you face-time and connection to faculty, fellow medical students, and residents/fellows. Even if you don’t end up in that specialty, you will be better off for learning first-hand what it’s all about. These experiences usually come in the form of shadowing or research.
While it’s great to explore specialties, you must realize that early in your medical school career you won’t have developed the ability to see the forest for the trees. It will be hard to wrap your head around what a field is really like. But any exposure is better than none.
4. Volunteer, aiming for depth.
As program directors looks at your CV, they come across “Health Fair Participant.” It’s the day you spent three hours doing blood pressure screens at the local supermarket on a Saturday. The world is a better place for you having taken the time to do so, but your application isn’t much better than it otherwise would have been.
Any selfless service is good, but it becomes very clear, very quickly, which experiences were one-offs for the sake of checking boxes, versus those that you poured your heart and soul into. Being the student who organized the quarterly health fairs, and liaised with businesses and faculty to make their dream of improving their community’s health a reality, speaks volumes. Showing up once just to say, “Yes, I volunteered,” just isn’t the same.
So, rather than having 35 one-offs on your application, get deeply into something, aiming to obtain a leadership role in a project that makes you happy.
5. Don’t blow off coursework!
When paradigms shift, sometimes the pendulum swings too far in the opposite direction. Sure, Step 1 scores have become inconsequential, but that isn’t an excuse to cruise through your early medical school classes, being satisfied with mediocrity. You should still give them your all, and aim to learn as much as possible. You will be surprised how often you have to revisit a concept which seemed so inane at the time you learned it, but actually proves valuable throughout your patient care experiences.
6. Play nice in the sandbox, aiming for a collaborative approach rather than a competitive one.
Your ability to work well with others is paramount in your evolving career. While there might be a drive to “do better than the next” student, you can do so in a collaborative manner. When you know things that other people don’t, you can cordially teach them, or you can publicly insult them on rounds for their lack of knowledge. EVERYONE will be better off if you take the first approach.
It all comes back to reputation. If you are arrogant, conniving, conceited, or self-centered, no wonderful scores or amount of knowledge will change your colleague’s negative opinion of you.
Regardless of what field you end up in, a large part of your success will be determined by how well you work with others. Find a way to be wonderful to everyone, and lift those up around you. Your attendings and residents will easily develop an idea of the kind of comrade you are to your equals.
What I’ve said here is probably nothing that you haven’t heard before. But sometimes we just need that little nudge in the right direction to see our not-so-wonderful behaviors, or to light the fire underneath us to do just a little bit more. In the era of a pass/fail Step 1, your character will become the centerpiece of your application. Your reputation will be the key in unlocking the doors to interviews. Find a way to hone yours, and that residency spot will fall into your lap.
An important heads-up. It will be a lot easier to find a way to exemplify these things on your applications if you are indeed living them. Taking a ho-hum approach to your education, coasting by, and then trying to spin your actions into a well-told narrative is not the way to go about it. Putting in the hours of dedication, exercising persistence, and being the most fantastic and empathic human you can be is 90%+ of the challenge. The telling of your story, getting recognized for your hard work, is no small feat either, but it will be far easier a task if you actually have something to show and be proud of.